Application

Contact Information

Applicant's Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Social Security Number*

Birthdate*

Race / Ethnicity*

Age*

Please enter a number from 18 to 150.

Marital Status*

Single
Married
Widower
Widow

Advance Directives

Do you have...*

Power of Attorney
Durable Power of Attorney
Guardian
Living Will
None of the above

Guardian Name*

First Last

Guardian Address*

Street Address Address Line 2 City State ZIP Code

Guardian Home Phone Number*

Guardian Work Phone Number*

Billing / Insurance

Medicare Number

Medicaid Number

Insurance Co.*

Policy Number*

Insured Name*

First Last

Private Pay

Senior Care

Health Department / DDA

Living Arrangement*

Emergency Contact Information

Emergency Name*

First Last

Emergency Relationship*

Emergency Phone Home*

Emergency Phone Work*

Emergency Phone Cell*

Physician Info

Medical Clinic*

Medical Clinic Phone*

Medical Clinic Address*

Specialist Name

Specialist Phone

Specialist Address

Clinic / Therapist

Clinic / Therapist Phone

Clinic / Therapist Address

Dentist Name

Dentist Phone

Dentist Address

Medical Condition

Eating*

Independent
Spoon-Fed
Tube Feedings
IV Fluids
Needs Assistance (Specify Below)

Specify*

Needs Assistance Addition Details

Toileting*

Independent
Incontinent Totally
Indwelling Catheter
Enemas (Specify frequency below)
Impaction Removal
Maintained on Tolieting Schedule
Incontinent Intermittently
Colostomy/Ileostomy Care
Needs Assistance (Specify below)

Additional Details (optional)*

Specify the enema frequency in this field (if applicable); Specify any information about the type of assistance required (if applicable).

Rehabilitative Nursing*

BID/More Frequently
Less Frequently per week
Evaluation Only
one visit per month
2-3 times per week
daily
weekly

Mobility*

Independent
Totally Dependent
Turn and Position
Climb Stairs
Transfer with Assistance
Bed/Chair Confined
Needs Assistance (Specify below)

Needs Assistance Details Below*

Please provide any special mobility details/concern required.

Decubiti / Wounds*

Superficial
Extensive (Specify Below)
No history of decubiti
none present but history

Extensive Describe (Number, Size, and Treatment)*

Personal Hygiene*

Independent ADLs (Dressing, Bathing)
Dependent ADLs (Dressing, Bathing)
Needs Assistance (Specify Details Below)

Personal Hygience Needs Assistance Details*

Please describe what types of personal assistance in regards to personal hygiene that are required.

Behavior*

Oriented-Time/Place/Person
Confused
Alert
Wanders
Adjusted to Situation
Memory-Recent/Remote
Depressed
Combative
Requires Physical/Chemical Restraints

Maintenance Nursing*

ROM
Heat Treatments
Meal Training
Bladder/Bowel Training
Suctioning/Tracheostomy
Reality Orientation
Ambulation
Oxygen/Aerosol
ADL Training

Devices*

Brace
Crutches
Walker
Cane
Prosthesis
Wheelchair

Impairments*

Hearing (Specify Details Below)
Sight (Specify Details Below)
Speech (Specify Details Below)

Hearing / Sight / Speech Additional Details*

Please specify details in this field.

Additional Information of Physical, Medical, or Mental Problems*

Reason(s) why I could benefit from the day care program*

Is participant own legal guardian?*

(Must be appointed by a court of law, anyone over the age of 18 is considered there own legal guardian.)

Yes
No

Full Name*

Phone*

Has Power of Attorney of Person or Property been appointed?*

Yes
No

Full Name*

Phone*

This letter is to reaffirm: The non-discrimination policy of the Charles County Nursing Rehabilitation Center (CCNRC) Adult Day Services Center; the Center which operates Monday through Friday from 8:00 a.m. to 4:30 p.m. at Route 6 and Route 488, 10200 La Plata Road, La Plata, Maryland, in compliance with the provision of the Civil Rights Act of 1964, and the Rehabilitation Act of 1973, Section 503 and 504.

Under these requirements, the Charles County Nursing Rehabilitation Center (CCNRC) Adult Day Services Center operates under the policy that no person shall be denied benefits of, or be subject to discrimination in the provision of any care or service on the grounds of race, color, national origin, ancestry, blindness, age, sex, religious creed, or marital status as a qualified handicapped individual.

Contact Information

Advance Directives

Billing / Insurance

Emergency Contact Information

Physician Info

Medical Condition

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